What is the treatment for colitis, specifically ulcerative colitis?

Treatment of Ulcerative Colitis

The first-line treatment for mild to moderate ulcerative colitis is oral mesalamine (5-ASA) at doses of 2-4g daily combined with topical mesalamine 1g daily for distal disease, with escalation to corticosteroids if inadequate response occurs after 2 weeks. 1, 2

Treatment Based on Disease Severity and Location

Mild to Moderate Disease

• Oral therapy:

  • Mesalamine 2-4g daily 2, 1
  • Once-daily dosing is as effective as divided doses and may improve compliance 2
  • Higher doses (4.8g/day) may be more effective for moderate disease 2
  • Alternative options: balsalazide (6.75g daily) or olsalazine (2-3g daily) 2

• For distal disease (left-sided colitis or proctitis):

  • Combine oral mesalamine with topical (rectal) mesalamine 1g daily 2, 1
  • Topical mesalamine is more effective than topical steroids 2
  • Combination of oral and rectal mesalamine is more effective than either alone 1

• Treatment duration:

  • If no improvement after 10-14 days with appropriate 5-ASA therapy, add oral corticosteroids 2
  • Complete remission may require up to 40 days of therapy 2

Moderate to Severe Disease

• Initial therapy:

  • Systemic corticosteroids (prednisolone 40mg daily) 1
  • Continue topical agents as adjunctive therapy 1

• For steroid-refractory disease:

  • Infliximab 5mg/kg IV at weeks 0,2, and 6, then every 8 weeks 1, 3
  • Adalimumab 160mg initially, 80mg at week 2, then 40mg every other week 4
  • Vedolizumab or tofacitinib may also be considered 1

• For steroid-dependent disease:

  • Azathioprine (1.5-2.5mg/kg/day) or mercaptopurine (0.75-1.5mg/kg/day) 1
  • Note: These have slow onset of action and cannot be used as sole therapy 1

Maintenance Therapy

• All patients should receive maintenance therapy 2, 1
• Recommended regimens:
  • Oral mesalamine ≥2g/day for long-term maintenance 2
  • Continue the same medication that induced remission 1
  • For patients maintained on biologics, consider monitoring with fecal calprotectin levels 1

Special Considerations

Monitoring and Follow-up

• Monitor for clinical response: reduction in stool frequency and rectal bleeding
• Assess for mucosal healing with endoscopy in patients on biologics
• Monitor for potential medication side effects

Common Pitfalls to Avoid

1. Inadequate dosing of 5-ASA compounds 1

   • Use at least 2g/day for mild disease and 4.8g/day for moderate disease

2. Delayed escalation of therapy 1

   • Escalate to steroids if no improvement after 2 weeks of mesalamine

3. Prolonged steroid use without steroid-sparing strategies 1

   • Implement steroid-sparing agents (thiopurines, biologics) for steroid-dependent disease

4. Failure to use combination oral and topical therapy for distal disease 2, 1

   • Combined therapy is more effective than either route alone

5. Not considering surgery when appropriate 1

   • Indications include: free perforation, life-threatening hemorrhage, toxic megacolon with clinical deterioration, or failure to respond to medical therapy within 48-72 hours

Supportive Care

• Avoid opioids due to risks of dependence, infection, and gut dysmotility 1
• Consider thromboembolism prophylaxis with subcutaneous heparin 1
• Provide nutritional support if malnourished 1
• Maintain hemoglobin >10g/dl 1

By following this evidence-based approach to treating ulcerative colitis, clinicians can optimize outcomes while minimizing risks associated with both undertreated disease and medication side effects.